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2014 NCSBN Scientific Symposium
April 2014
Christine Szweda, MS, BSN, RN Senior Director, Operations
Office of Nursing Education and Professional Development
Objectives
• Participants can state the rationale for the proposed research study
• Participants can describe the intervention
• Participants can identify one area for future study
Cleveland Clinic National Recognition
• U.S. News & World Report - #1 in heart care 19 consecutive years - In top 4 hospitals nationally
H Fairview Hospital
Lakewood Hospital
H
Lutheran Hospital
H
Euclid Hospital
H
Hillcrest Hospital
H
South Pointe Hospital
H
Marymount Hospital
H
Cleveland Clinic
(main campus)
Integrated Health System serving 5.1 million patients
H Medina Hospital H Weston Hospital,
Florida
• Total workforce >41,000 • Nurses 11,000+
• 154 nursing units • 4,500 beds • 200 operating room settings • ER visits (system wide) – 440,000
Cleveland Clinic Nursing
Annual RN Hires
2011
1750
2013
1250
2012
1500 Types of New Hires
18%
82%
ExperiencedInexperienced
40% New Graduate Nurses Hired into
an ICU Setting
Study Overview Evaluating the Use of Human Patient Simulation
(HPS) to Improve Critical Thinking Competencies and Perceived Self-Confidence of New Graduate Nurses in the Intensive Care
Unit (ICU)
• Could an intensive educational program utilizing HPS scenarios significantly improve new
graduate RN’s critical thinking competencies and perceived self-confidence in managing patient
problems in the ICU setting?
Study Methods
• Part A - A mixed methods study with double-blind randomized trial
• Part B - A qualitative component utilizing individual interviews
• Study Tools - PBDS© Competency Assessment Tool - Casey Fink Graduate Nurse Experience
Survey - Qualitative Interview Tool
Expectations at Point of Hire
• Recognition of Problem • Recognition of Urgency
Expectation of New Graduate Nurses upon entry to CC Health System
PBDS Continuum Baseline Assessment
Unable to recognize
change problem or
urgency
Unable to manage basic
med/surg patient
problems
Acceptable
Percent of New Graduates in Each Category
35%*
54% 11%
Unsafe to transition to hospital unit
Expectations at End of Orientation
• Management of Problem - Communicate Relevant Info to MD - Anticipate Orders from MD - Implement Immediate Nursing
Interventions Expectation of New Graduate Nurses upon completion of orientation
PBDS Continuum Re-assessment
Unable to recognize
change problem or
urgency
Unable to manage patient
problems specific to their
unit
Acceptable
Percent of ICU Nurses in Each Category
15%
55% 30%
Percent of Med/Surg Nurses in Each Category
10% 20% 70%
Participants
• Consented 65 - 31 intervention group - 25 control group
Intervention
• Control Group - Standard 12 weeks of orientation with
a coach/preceptor - Critical care classes scheduled
throughout orientation
Intervention
• Experimental Group - Standard 12 weeks of orientation with
a coach/preceptor - Critical care classes scheduled
throughout orientation • Five day immersive experience focused
on ICU problem management
Day 1 Day 2 Day 3 Day 4 Day 5 Review week
Review critical thinking questions
Practice critical thinking questions with video scenarios
Intro to hi-fidelity simulation
HPS Scenario – Uncontrolled Pain
Debriefing
Equipment Review
Review Scenario SBAR
HPS Scenario – Hypovolemia
Debriefing
Equipment Review
Review Scenario SBAR
HPS Scenario – Sepsis
Debriefing
Equipment Review
Review Scenario SBAR
HPS Scenario – Obstucted Airway
Debriefing
Compare and Contrast with video scenarios and critical thinking questions
Debriefing
Equipment Review
Review Scenario SBAR
HPS Scenario – DKA
Debriefing
Review Scenario SBAR
HPS Scenario – Pulmonary Edema
Debriefing
Individual HPS Scenarios
Review video – self assess
Present video to cohort and debrief
Prioritization exercise (all scenarios from week)
Critical Thinking Questions
Review SBAR/Receive Handoff Report • What complications is the patient at risk for? • How will you know if that complication is occurring? • What particular components of the assessment are
you going to focus on?
Critical Thinking Questions Assess the patient • What signs/symptoms do you see? • What problem/complication do you think is occurring
and why? • Does this require any urgent action(s) and why? • What immediate nursing interventions do I need to
take and why? • What information do I need to communicate to the
physician? • What orders am I going to anticipate from the
physician? • What is the rationale for those orders? • How will I know the interventions/orders implemented
have been effective?
PBDS Re-assessments Unable to recognize
change problem or
urgency
Unable to manage patient
problems specific to their unit
Acceptable
Pre-Study 15%
55% 30%
Control Group 4% 62% 44%
Experimental/ Intervention Group
0% 61% 39%
Qualitative Findings
• Experimental/Intervention group identified 3 themes - Improved their ability to see the
entire patient picture - Taught them to anticipate problems
and/or complications and know what to expect
- Communicate more effectively with the MD and anticipate appropriate orders.
Qualitative Findings
• Top Lessons Learned - Improved assessment skills - Learned the why behind the
interventions - Ability to prioritize - Pattern of critical thinking to use
when approaching patients
Qualitative Interviews
• Themes - Learn best on unit with coach instead of in
classes - Time away from unit increased stress in
some - Even when practicing independently, did
not feel confident in understanding the entire patient picture
- Coaches who asked questions preferred to those who just showed how things were done
Recommendations
• Further study on an intervention that allows for time on unit with coach and minimal class content.
• Compare relationship between perceived confidence and competency.